April 2, 2014

Obamacare Is Doomed! A Trip Down Memory Lane.

On Tuesday morning President Obama congratulated the visiting Boston Red Sox on their victory in last year’s World Series. On Tuesday afternoon, Obama congratulated himself and his staff on a a different kind of triumph—getting 7 million insurance signups before the official end of Obamacare’s open enrollment period. You could see that Obama was having fun in the morning, mugging for a selfie with David Ortiz (Papi’s idea) and warning the champions that his Sox, the White Sox, might be the better team this year. But you could tell that Obama felt even better during the afternoon, standing before his supporters and allies, reminding everybody just why they had fought so hard for reform in the first place.

Really, who could blame him? The 7 million target for enrollment, first issued by the Congressional Budget Office back in 2010, has assumed a mythical status in the debate over the Affordable Care Act. And as you’ve doubtless heard or read by now, meeting that goal means less than everybody seems to realize. It doesn’t reveal what kind of people bought plans or how many paid for them, or how the numbers break down state-by-state, or what it means for the total number of uninsured Americans. But 7 million does show that lots of people are using the new system to get insurance, more or less as the real experts had long predicted. And it comes with other signs that the law is doing what it's supposed to do, though the evidence on that is a lot more murky. As I've said before, the signup figures may not show that Obamacare works well. But they show that Obamacare works.

And that's not something much of the Washington establishment, particularly on the right, seemed to think possible. Ever since October 1, when the launch of healthcare.gov went awry, politicians and pundits have been issuing warnings of doom. And whenever the Administration proved one of these predictions wrong, by crossing some threshold or achieving some milestone, the critics simply came up with new disasters the program could not overcome. First they said the website would never work well enough. Then they said faulty insurance data would cause mass chaos. Then they said enrollment would remain far below targets, low enough to threaten the system’s viability.

Some of the most predictably dire quotes came from Republican politicians like House Speaker John Boehner. Reacting in November to news that less than 50,000 people had signed up for private health insurance plans, he called Obamacare "a rolling calamity that must be scrapped" and said "When you step back and look at the totality of this, I don’t think it’s ever going to work." Other members of the Republican doom chorus included Senator Orrin Hatch, who said “At this pace, the Obama Administration will never be able to meet their enrollment goals" and Congressman Dave Camp, “Even if this data was an accurate picture, the Administration would need to enroll 68,000 people per day to meet their year-end goal.” And then there was Representative Darrell Issa, who said “It is time for the president to finally acknowledge ObamaCare isn’t working and to delay the law, in fairness to families and individuals.” Once enrollment finally picked up, Republicans began talking about “death spirals”—the possibility that plans would attract too many older and sicker people, wreaking actuarial havoc and inviting a massive “bailout” of the insurance industry. “It looks to me like we are going to end up in what's called an insurance death spiral,” said Senator John Barrasso. “It's going to go down, down, and then you are looking at, to me, a massive government bailout of this entire health care law.”

But politicians always talk in hyperbole. Members of the press—yes, even the opinion press—are supposed to be more careful. But pundits, particularly conservative ones, were just as sure that failure was imminent. Here was Victor David Hanson of Naitonal Review, back in November: “In the next 90 days, the Obama administration will have to declare victory and then abandon most of Obamacare.” And here was Jay Cost of the Weekly Standard, in February: “It is clear by now that the administration will not reach the original CBO estimate of 7 million enrollees by the deadline at the end of March.” Conn Carroll spoke of the law's "imminent demise." Perhaps nobody was more confident of failure than conservative strategist Bill Kristol. "Obamacare is failing and will fail," he said on Meet the Press. "And I'm very much looking forward to being on this show with [fellow panelist and Obama advisor David Axelrod] in January of 2017 when finally all of Obamacare is repealed."

Some of the most severe warnings came from bona fide wonks—people who know health care and know it well. When healthcare.gov remained barely operational in early November, Robert Laszewski, an insurance industry consultant and blogger, wrote that “It is now becoming clear that the Obama administration will not have Health.care.gov fixed by December 1 so hundreds of thousands, or perhaps millions, of people will be able to smoothly enroll by January 1.” A few weeks later, he said “It will likely be at least late January or early February before not just HealthCare.gov but the other key information systems supporting the new law are built and repaired to just minimal standards.”

That prediction, widely shared, did not come true. The system worked well in December, handling a rush of applicants trying to get coverage in time for January 1. But the predictions kept coming, even as enrollment climbed. Maybe my favorite of the entire genre was a story in the Daily Caller, published after the government reported 4.1 million people had signed up. The headline said “New enrollment numbers suggest Obamacare is hurtling toward failure.” The story, by Sarah Hurtubise, explained that February’s enrollment was lower than January’s. (Like most writers, she didn’t account for the fact that February had fewer days.) Then it predicted “At this rate, it’s not likely that they’ll be able to bring in over 1.8 million in one month to meet even their diminished goal.”

In the final days of open enrollment, as it became clear the raw signup number would approach if not exceed 7 million, conservative outlets finally recognized reality—though grudgingly. A lead March 31 headline on Fox News warned that "Technical problems pose roadblock to those looking to beat Obamacare deadline." And Rush Limbaugh? He told listeners not to believe what they were reading. "These numbers are obviously not believable. They're obviously cooked. There's no question."

The problem with these predictions wasn’t their pessimism per se. The Obamacare websites really did have catastrophic problems for the first few weeks. They really were sending flawed data to the insurers. Enrollment really did lag for a while. Younger and healthier people really were slow to sign up—and, even now, may be underrepresented to the point that insurers have to raise rates next year. The problem with the politician and pundit predictions was the absolute conviction that these flaws were fatal, rather than problems that the Administration might find a way to fix.

Not every commentator was so convinced. Ross Douthat, the New York Times columnist, was a rare voice of perspective on the right. He expressed shock at the way the administration bungled the website launch—but reminded readers that, at the end of the day, the White House and its allies could probably figure out how to make a website run. Steve Benen and Greg Sargent urged patience. Garance Franke-Ruta reminded Atlantic readers that “there are uninsured who need health insurance, and they will need it whether or not it is easy to get.” In December, after a surge of pre-Christmas signups from people who wanted coverage in time for January, Sarah Kliff wrote “what seemed impossible in October suddenly became a lot more plausible in late December. … Health policy experts now see a space to get to 7 million -- although it's by no means a guarantee.”

I, too, counseled against panic and deafetism—noting that enrollment had gotten off to a slow start in Massachusetts, when it tried reform, and the Administration had time to get things right. After that first, extremely discouraging report about signups in October, I wrote

"Me? Barring unforeseen developments or wrinkles in this report, I’m sticking with my story. The October numbers are low, which was to be expected given the website problems and tendency of people not to buy insurance right away. But what matters isn’t the figures for October or even November. It’s December and the months that follow—particularly into next year, as the prospect of paying fines for uninsurance start to hit people in the face. 'It's too early to say anything useful,' says Jonathan Gruber, professor of economics at MIT. 'And, really, I don't think we can draw any significant conclusions about effectiveness of the law until March, because any firm conclusion requires effects of individual mandate to be felt.'"

Earlier this week, health care writer Dan Diamondsuggested I take a victory lap for that prediction. He is kind—too kind, I think. Like everybody following the health care story, I wish I had written some things differently. My stories from earlier in 2013 warned of website problems, but not a total failure. (Laszewski, the insurance blogger, was one of the few who got that one right.) And while I predicted that some people would pay more for coverage, I didn't write that insurers would actually cancel their plans. Still, those of us who got the enrollment predictions right did so for two very simple reasons. We listened to what people with actual knowledge (inside or outside) told us about what was happening. And we avoided rash or predictions of extreme success or failure, because such statements almost never come true.

Those are good rules for talking about health care policy—or any big debate, for that matter. And maybe the best thing about Tuesday at the White House was listening to Obama adopt a similarly measured tone. “In the months, years ahead, I guarantee you there will be additional challenges to implementing this law,” he said. “There will be days when the website stumbles -- I guarantee it. … There will be parts of the law that will still need to be improved." The president was right. Obamacare's future will include rough patches, just as its past did. That won't preclude success and it certainly won't make it a catastrophe.